FOCAL INFECTION IN THE NASAL SINUSES CAUSING OCULAR AND OTHER SYSTEMIC INFECTIONS.1

Pliable diagnostic findings, e.g. canalicular optic neuritis and ?ther peripheral neuritis, rheumatoid arthritis, neurasthenia, Cental depression and even insanity. The existence of frontal sinusitis in doubtful cases may dually be diagnosed by means of good skiagrams and ^rther corroborated by passing a fine cannula into the sinus blowing air so as to cause any secretion from the sinus *? appear at the lower end of the fronto-nasal duct. In antral sinus infection transillumination is so unreliable

The purport of these notes is not to survey the question of nasal infections as the causal factor in various systemic affections, nor even to discuss the manifold symptoms attributable to such focal infection, but to explain briefly s?me developments in technique for locating precisely, or Positively excluding, the existence of a nasal source of Section in cases where the consequences of focal infection render it a matter of considerable importance to obtain Pliable diagnostic findings, e.g. canalicular optic neuritis and ?ther peripheral neuritis, rheumatoid arthritis, neurasthenia, Cental depression and even insanity.
The existence of frontal sinusitis in doubtful cases may dually be diagnosed by means of good skiagrams and ^rther corroborated by passing a fine cannula into the sinus blowing air so as to cause any secretion from the sinus proved infected, it does not follow that they are the chief ?r sole source or even the source at all of a canalicular neuiitlS' unless one can be certain that the other sinuses which mig^ cause the neuritis have been explored and proved sterile-Diagnostic exploration by the suction syringe can be done under local anesthesia by cocaine, tutocain or eucaine, etc-' in all but children or highly nervous adults for whom a lig^ general anaesthetic is desirable.
For each sinus explored one should use a separate ste syringe and cannula. After entering a sinus a little ste warm water may be injected to mix with any discharge lyin? in the cavity, and then sucked back into the syringe, yielding, so to speak, a " deep-sea fishing" sample of the sinus contents. After detaching the cannula, the contents of the syringe is emptied into a sterile bottle for examination by stained film and culture.
The maxillary antrum may be entered either through the thin bone of the upper part of the inferior meatal wall 0r through the far thinner wall of the middle meatus (as sho\vn in the diagram), and to anyone accustomed to the tatter route it is a very simple and painless method.
The sphenoidal sinus is entered by passing the blunt trocar and cannula through the thin anterior wall, care being t^ken to avoid using any force. Ihe sensation of resistance Overcome indicates the entry of the top of the cannula into tlle sinus, and it is passed until it impinges against the   Showing above the cannula passed into the maxillary antrum through the middle meatus, and below the same with the short cannula through the thin inferior antromeatal wall. Showing above the cannula passed into the maxillary antrum through the middle meatus, and below the same with the short cannula through the thin inferior antromeatal wall. posterior wall of the sinus ; the sensation of contact with a bony wall being characteristic and hardly mistakable-Having thus entered the sphenoidal sinus cavity, the blunt trocar is withdrawn and the syringe attached to the proximal or projecting end and the sample of the investigated sinus content sucked into the syringe. If much pus is lying in the sinus, it may appear in the syringe in ropes, or as very diu mucus, leaving one in no doubt as to the sinus being infec In other cases the fluid extracted may be perfectly clear a watery, proving sterile on culture. Other samples obtaine may be suspicious only, and doubtful until submitted to and culture examinations, which may either prove nega FlG' 3' 'al Transverse horizontal section of the head showing the floor of the mtracra'1'^ anterior fossa. Posteriorly the optic chiasma divides, and the right optic 1 ^ is displayed passing forwards to the right eye and shirting the small sphenoidal sinus and posterior ethmoidal cell. Exploring cannula shown entering the right and left nasal passage, but their distal extreW are seen lying side by side in the large exposed left sphenoidal sinus. one sphenoidal sinus may be very large and extend right across the mid-line, pushing the sinus of the other side, which is correspondingly small, so far outwards that the exploring cannulae passed backwards through the right and left nasal passages have to be entered through the one large sinus, the other small one being missed {vide Fig. 3). This is not difficult to discover if, with both cannuke in the sphenoidal sinus or sinuses, one injects fluid down one, for if both cannuke be in one and the same cavity the fluid will rise up the other and escape by the open end, whereas if the two cannuke are in separate sinuses the fluid injected down one cannula cannot escape by the other. Similarly a posterior ethmoidal cell may be so large and extend backwards so deeply that it encroaches on the corresponding sphenoidal sinus, and then one may be One cannula has entered the Rsphenoidal sinus, the other has been passed into the R. posterior ethmoid cell.

REVIEWS OF BOOKS.
127 feft in doubt as to whether one has entered the sphenoidal Slnus instead of the ethmoidal cell. By again keeping both cannulae in situ and injecting water down one it is quite easy t? determine whether the two cannula lie in the same or in Separate cavities. Such precautions are by no means fanciful, and I have met with cases of canalicular optic neuritis where the sinus infection did not correspond with the retinal defects until further careful exploration revealed such ^regularities as I have described, and which had very nearly to the source of the very serious ocular defect being missed and the patient unrelieved.